C L I N I C I A N S

C O R N E R

Primary Pterygium
RASIK B. VAJPAYEE, M.B.B.S., M.S.
Clinical Professor of Ophthalmology, Head, Cornea & Refractive Surgery Services, RP Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India JUAN CAMILO SANCHEZ-THORIN, M.D. Institutional Member, Ophthalmology Department, Fundacion Santa Fe de Bogota, Bogota, Colombia

WHAT IS YOUR APPROACH TO PRIMARY PTERYGIUM?

Dr. Vajpayee: My approach to primary pterygium depends on the stage of pterygium. If its a small/atrophic pterygium causing no/minimal symptoms, then I prefer to manage it medically with the use of articial tears and naphazoline eye drops. If the pterygium is eshy and causing signicant astigmatism, then I prefer to excise it and do autologous conjunctival transplant. The rationale behind the use of autoconjunctival transplant is based on the fact that close approximation of healthy conjunctival tissue at the denuded limbus after pterygium excision prevents recurrences. After excising the pterygium, I also excise 1 to 2 mm of subconjunctival tissue peripheral to the areas surrounding the excised pterygium. This might help in preventing recurrence. I usually harvest the conjunctival graft for transplant from the superotemporal bulbar conjunctiva of the same eye. The size of the bare sclera is measured with the Castroviejo calipers. The same size is marked on the donor site with gentian violet. This marking not only helps in excision of the appropriate size graft but also helps in proper upside-down orientation of the graft on the recipient bed. The conjunctival graft should be thin and free of Tenons to prevent postoperative shrinkage. The graft is secured in place with interrupted 80 Vicryl (polyglactin) sutures.1 Postoperatively I prescribe topical antibiotics and topical corticosteroid drops for 2 weeks and ocular lubricants for 4 weeks.

Dr. Sanchez-Thorin: My approach is denitely bare sclera resection and conjunctival autograft. A meta-analysis2 published a few years ago demonstrates the benets of this technique with regard to a signicant reduction in recurrence rates as compared with bare sclera resection per se or this procedure in conjunction with mitomycin application. Obviously, eyes with glaucoma ltering procedures are excluded from this technique.

HOW DOES YOUR APPROACH DIFFER IN RECURRENT PTERYGIUM? WHEN DO YOU CONSIDER THE USE OF MMC IN THE MANAGEMENT OF PTERYGIUM, AND HOW DO YOU USE IT?
Dr. Vajpayee: For recurrent pterygium I rst evaluate the patients previous surgical record to know whether this is the rst recurrence or multiple recurrences have occurred. In the records I also like to see the nature of previous surgery (i.e., whether bare sclera was left or autoconjunctival transplant was performed). If it is a case of rst recurrence and the previous surgery was a bare sclera technique, then I excise the pterygium and do an autologous conjunctival transplant. However, if its a case of multiple recurrences/rst recurrence with a previous autoconjunctival transplant, I prefer to use mitomycin C in these cases. The pterygium is excised and a cellulose sponge soaked in 0.02% of mitomycin C is placed over the bare sclera for 2 minutes. A copious irrigation is performed to remove all remnants of mitomycin C, keeping in mind the toxicity of this drug. This is followed by autoconjunctival transplant. The patient is meticulously and regularly followed up to look for any postoperative scleral melting.

Address correspondence and reprint requests to Rasik B. Vajpayee, M.B.B.S., M.S., Clinical Professor of Ophthalmology, Head, Cornea & Refractive Surgery Services, RP Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi 110029, India; e-mail: rasikvajpayee@rediffmail.com or Juan Camilo Sanchez-Thorin, M.D., Avenida 9 No. 11720 (908), Bogota, Colombia; e-mail: csnthor@hotmail.com

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G. Rocha

Dr. Sanchez-Thorin: My approach does not differ; however, if various recurrences have occurred or in the presence of symblepharon or muscle retraction I use topical mitomycin C 0.05% applied intraoperatively. The use of mitomycin C is restricted to eyes with at least a third recurrence, symblepharon, or retraction enough to induce permanent ocular deviations. I use it in a 0.05% concentration and apply an imbibed Weck cell sponge over the underlying area for 2 minutes before rinsing.

REFERENCES
1. Vajpayee R. Two pearls for successful pterygium excision. In: Melki SA, Azar DT, eds. 101 Pearls in refractive, cataract, and corneal surgery. Thorofare, NJ: Slack, 2001:121124. 2. Sanchez-Thorin JC, Rocha G, Yelin JB. Meta-analysis on the recurrence rates after bare sclera resection with and without mitomycin C use and conjunctival autograft placement in surgery for primary pterygium. Br J Ophthalmol 1998;82:661665.

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Techniques in Ophthalmology